Consultation

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This form will be sent to our Physician for review.

Step 1 of 9 - GOALS

Height (feet)*

Please enter a number from 1 to 9.

Please enter just the feet, and then in the next field enter in inches. So if you are 5'11, please enter in 5 this field and 11 in the next field.

And Inches*

Please enter a number from 0 to 11.

Weight (lbs)*

Please enter a number from 75 to 1200.

BMI

Which options would you like? - (If physician does not approve, this amount will be fully refunded.)

Tirzepatide Options:

OUR TIRZEPATIDE FORMULATION CONTAINS THE FULL DOSE OF TIRZEPATIDE, PLUS GLYCINE AND B12. PLEASE READ THE PRODUCT PAGE FOR MORE INFORMATION. IF YOU HAVE ANY QUESTIONS PLEASE EMAIL US. TIRZEPATIDE IS A TITRATED PRODUCT. IF YOU ARE TAKING IT FOR THE FIRST TIME, YOU MUST START AT THE MONTH 1 DOSE, AND TITRATE UP MONTHLY AS NEEDED.

1st MONTH - Tirzepatide Injection Homekit (4 injections, 28 day supply)

2.5mg per week for 4 weeks (Tirzepatide/Glycine/B12)

Price: $185.00

2nd MONTH - Tirzepatide Injection Homekit (4 injections, 28 day supply)

5mg per week for 4 weeks (Tirzepatide/Glycine/B12)

Price: $299.00

3rd MONTH Tirzepatide Injection Homekit (4 injections, 28 day supply)

7.5mg per week for 4 weeks (Tirzepatide/Glycine/B12)

Price: $399.00

4th Month - Tirzepatide Injection Homekit (4 injections, 28 day supply)

10mg per week for 4 weeks (Tirzepatide/Glycine/B12)

Price: $449.00

5th Month - Tirzepatide Injection Homekit (4 injections, 28 day supply)

12.5mg per week for 4 weeks (Tirzepatide/Glycine/B12)

Price: $499.00

6th Month - Tirzepatide Injection Homekit (4 injections, 28 day supply)

15mg per week for 4 weeks (Tirzepatide/Glycine/B12)

Price: $599.00

Semaglutide Weight Loss Program

Semaglutide Options:

OUR SEMAGLUTIDE INCLUDES A FULL DOSE OF SEMAGLUTIDE PLUS B12. SEMAGLUTIDE IS A TITRATED PRODUCT. IF YOU ARE TAKING SEMAGLUTIDE FOR THE FIRST TIME, YOU MUST START AT THE MONTH 1 DOSE, AND TITRATE UP MONTHLY AS NEEDED.

1st MONTH - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply)

0.25mg per week for 4 weeks

Price: $135.00

2nd MONTH - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply)

0.5mg per week for 4 weeks

Price: $245.00

3rd MONTH - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply)

1.0mg per week for 4 weeks

Price: $295.00

4th MONTH - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply)

1.7mg per week for 4 weeks

Price: $345.00

MAINTENANCE DOSE (ongoing) - Semaglutide/B12 Injection Homekit (4 injections, 28 day supply)

2.4mg per week for 4 weeks

Price: $395.00

Current Medication SAMPLES Available:

SAMPLE Tirzepatide 1-Dose Injection Homekit (1 injection, 1 week supply)

1 Injection of 2.5mg - Try it before you buy it. This is the first dose of Tirzepatide/Glycine/B12 2.5mg

Price: $99.00

SAMPLE Semaglutide 1-Dose Injection Homekit (1 injection, 1 week supply)

1 Injection of 0.25mg - Try it before you buy it. This is the first dose of Semaglutide/B12 0.25mg

Price: $99.00

Choose a Shipping Option:*

FedEx 2-Day (Ships M-F) (PLUS Pharmacy Processing Time2-5 Days) -$10.00

FedEx Overnight (Ships M-Th) (PLUS Pharmacy Processing Time 2-5 Days)

FedEx Priority Overnight (Ships M-F and Saturday Delivery) (PLUS Pharmacy processing time 2-5 Days) +$20.00

Coupon (Not Valid for SALE products)

NOTES

Add a note (optional)

Total

(If physician does not approve, this amount will be fully refunded.)

Phone Number*

This is the Phone Number the Doctor will use to call you, if necessary. Please double check to make sure that it is correct.

BILLING ADDRESS*

Street Address City State ZIP Code

Billing Address Same as Shipping Address?

Yes

SHIPPING ADDRESS*

Street Address City State ZIP Code

License or Government ID

Max. file size: 256 MB.

If you are unable to upload, please email it to info@vitastir.com

REQUIRED "HOW TO" VIDEO*

I have watched the video and know how to give myself an injection

www.vitastir.com/howtoinject (VIDEO AVAILABLE HERE)

I WILL FOLLOW THE INSTRUCTIONS AND DOSAGE AMOUNTS ON MY BOTTLE. I understand these injections are to be self injected in the area written on my bottle. I will watch the video to learn how to self-inject. I am aware the instructional video is available to watch at www.vitastir.com/howtoinject. I agree I will use the syringes and vitamins as directed.*

I Agree

I understand that my custom package is ordered for me. My vial or package I start at VITAstir will have an expiration date that is 28 days after opening. I understand, after the 28 day period, medications are considered expired and should be discarded by me.*

I Agree

I understand that my medication is prepared in a compounding pharmacy in accordance with Section 503A of the Federal Food, Drug, and Cosmetic Act and is dispensed solely pursuant to a valid patient-specific prescription from a licensed healthcare provider. If I am ordering Tirzepatide, I undertand the following: This compounded medication contains Tirzepatide combined with glycine and vitamin B12, and is formulated specifically for individual patients who may not tolerate standard formulations or who require a customized therapeutic approach. It is prepared in accordance with Section 503A of the Federal Food, Drug, and Cosmetic Act and is dispensed solely pursuant to a valid patient-specific prescription from a licensed healthcare provider. Our compounded formulation is not affiliated with, endorsed by, or intended to replace the FDA-approved product manufactured by Eli Lilly. The addition of glycine and vitamin B12 is intended to support patients experiencing issues such as fatigue, muscle loss, or neuropathy—common concerns during weight loss or diabetes treatment—and may offer metabolic, neurological, and musculoskeletal benefits. This medication is not made for resale, bulk distribution, or office use, and is compounded exclusively to meet the clinical needs of individual patients when commercially available alternatives are not appropriate.*

I Agree

CONSENT FORM: I acknowledge that I have received instructions and educational material from VITAstir for the administration of home injections. I acknowledge that the risks of injections has been discussed with me. I understand that these risks include, but are not limited to, local reactions, rashes, bruises, etc. - I understand that if I elect to do self-administered injections or if another designated individual gives me the injection, I should be attended for at least 30 minutes by a responsible adult to assist me in case of a severe reaction. - I agree to have on hand an epinephrine injector to use in case of a systemic reaction. I acknowledge that I have received instruction on its use and administration. I further understand that I must identify that the date of this medication is current. If not, I will call for a renewal of my medication. - I understand that it is my responsibility to maintain follow up appointments with my physician at VITAstir as needed. By signing this form, I assume full responsibility for receiving my injections and release VITAstir and its physicians from any liability or responsibility for any reactions, conditions, self-injection procedures or injuries in conjunction with the injection therapies. I also understand that I am able to use VITAstir services and go to any pharmacy of my choosing.*

I AGREE

NO RETURNS - I UNDERSTAND THIS IS A NON-REFUNDABLE PRODUCT AND CANNOT BE RETURNED. I AGREE TO THE REFUND POLICY AVAILABLE AT www.vitastir.com/refund-policy/ - I authorize VITAstir to charge my credit card for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.*

I Agree

I agree to give my consent to treat. I have read the Telehealth Consent located at www.vitastir.com/consent*

I Agree

I agree to VITAstirs Terms and Conditions. I have read the Terms and conditions located at https://www.vitastir.com/terms-and-conditions/*

I Agree

PRINT NAME. I HAVE READ THE ABOVE CONSENT FORM AND AGREE TO E-SIGN. (First and Last Name)*

SIGNATURE*

Date SIGNED (mm/dd/yyyy):*

(If physician does not approve, this amount will be fully refunded.)

Total

(If physician does not approve, this amount will be fully refunded.)

Credit Card*

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

ONE-TIME OR SUBSCRIPTION ORDER?*

ONE-TIME ORDER ONLY

RECURRING SUBSCRIPTION 20% OFF (Start getting 20% off when this rebills every month. Automatically applied at rebilling)

You can choose to make this order a one-time order or plan to get it delivered every month on a recurring subscription. ALL recurring subscription orders receive 20% off. (If you are choosing to have recurring orders of Semaglutide or Tirzepatide, you are agreeing to a titrated dosing schedule and charges for higher doses) Monthly subscription will be billed and shipped EVERY 25 DAYS. (If you have chosen a Tirzepatide of Semaglutide 1-Dose kit and choose to have recurring subscriptions, your next dose will be the 1-Month homekit and will be billed after 7 days.) Cancel anytime at least 48 hours before next billing cycle by emailing info@vitastir.com

OFFERS

Consultation

WHAT ARE YOUR GOALS?

Which options would you like? - (If physician does not approve, this amount will be fully refunded.)

Most Popular:

Tirzepatide Options:

Semaglutide Weight Loss Program

Semaglutide Options:

Current Medication SAMPLES Available:

(If physician does not approve, this amount will be fully refunded.)

OFFERS